Area under the concentration-time curve to minimum inhibitory concentration ratio as a predictor of vancomycin treatment outcome in methicillin-resistant Staphylococcus aureus bacteraemia.

There have been few clinical studies on the association between the 24-h area under the concentration-time curve (AUC24) to minimum inhibitory concentration (MIC) ratio and vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infections. Patients with MRSA bacteraemia between July 2009 and January 2012 were analysed retrospectively. All adult patients treated with vancomycin for ≥72 h without dialysis were included. The MIC was determined by Etest and broth microdilution (BMD). Initial steady-state AUC24 was estimated using a Bayesian model, and the AUC24/MIC cut-off value for differentiating treatment success and failure was calculated by classification and regression tree (CART) analysis. In total, 76 patients were enrolled; vancomycin treatment failure occurred in 20 patients (26.3%). Catheter-related infection was the most frequent (35.5%), followed by surgical site infection (26.3%), whilst 25 (32.9%) had complicated infections. In univariate analysis, decreased MRSA vancomycin susceptibility (MIC≥1.5 mg/L) and vancomycin trough levels (15-20 mg/L) were not associated with treatment outcomes. In the CART analysis, low initial vancomycin AUC24/MIC (<430 by Etest; <398.5 by BMD) was associated with a higher treatment failure rate (50.0% vs. 25.0%, P=0.039 by Etest; 45.0% vs. 23.2%; P=0.065 by BMD). In multivariate analysis, low initial vancomycin AUC24/MIC was a significant risk factor for treatment failure [adjusted odds ratio (aOR)=4.39, 95% confidence interval (CI), 1.26-15.35 by Etest; aOR=3.73, 95% CI 1.10-12.61 by BMD]. In MRSA bacteraemia, a low initial vancomycin AUC24/MIC is an independent risk factor for vancomycin treatment failure.

Jung Y ，Song KH ，Cho Je ，Kim HS ，Kim NH ，Kim TS ，Choe PG ，Chung JY ，Park WB ，Bang JH ，Kim ES ，Park KU ，Park SW ，Kim HB ，Kim NJ ，Oh MD ... -  《-》

Impact of area under the concentration-time curve to minimum inhibitory concentration ratio on vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus bacteraemia.

There have been few clinical studies on the association between the vancomycin 24-h area under the concentration-time curve (AUC24) to minimum inhibitory concentration (MIC) ratio and vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infections. To examine this association and to establish a suitable cut-off value for AUC24/MIC, a multicentre prospective observational study was conducted in patients with MRSA bacteraemia. Data were collected on all patients aged ≥18 years with MRSA bacteraemia treated with vancomycin for ≥72 h without dialysis. The MIC was determined by broth microdilution (BMD) and Etest. Treatment failure was defined as (i) 30-day mortality, (ii) persistent bacteraemia (≥7 days) and (iii) recurrence (≤30 days after completion of therapy). AUC24 was estimated by a Bayesian approach based on individual vancomycin concentrations. The AUC24/MIC cut-off value for differentiating treatment success and failure was calculated by Classification and Regression Tree (CART) analysis. In total, 117 patients were enrolled, among which vancomycin treatment failure occurred in 38 (32.5%). In univariate analysis, high vancomycin MIC and low trough levels were unrelated to treatment outcomes. In the CART analysis, low vancomycin AUC24/MIC [<392.7 (BMD) and <397.2 (Etest)] was associated with treatment failure. In multivariate analysis, low AUC24/MIC was a risk factor for treatment failure [adjusted odds ratio (aOR)=3.50, 95% confidence interval (CI) 1.39-8.82 by BMD; aOR=5.61, 95% CI 2.07-15.24 by Etest]. AUC24/MIC is associated with vancomycin treatment outcomes in MRSA bacteraemia, and seeking individualised AUC24/MIC ratios above target (>400) may improve treatment outcomes.

Song KH ，Kim HB ，Kim HS ，Lee MJ ，Jung Y ，Kim G ，Hwang JH ，Kim NH ，Kim M ，Kim CJ ，Choe PG ，Chung JY ，Park WB ，Kim ES ，Park KU ，Kim NJ ，Kim EC ，Oh MD ... -  《-》

Predicting high vancomycin minimum inhibitory concentration isolate infection among patients with community-onset methicillin-resistant Staphylococcus aureus bacteraemia.

Methicillin-resistant Staphylococcus aureus (MRSA) isolates with an elevated vancomycin MIC ≥2 mg/L have been increasingly identified in many countries. We aimed to develop a clinical score to predict vancomycin MIC ≥2 mg/L in patients with community-onset MRSA bacteraemia. This retrospective cohort study enrolled 394 patients with MRSA bacteraemia. Vancomycin MICs of all MRSA isolates were determined by agar dilution method. Clinical characteristics between patients with high (≥2 mg/L) and low (≤1 mg/L) vancomycin MIC MRSA bacteraemia were compared. Independent predictors of high vancomycin MIC isolate infection were identified and used to create a score-based predictive model. Among the 394 study patients, 56 (14.2%) had MRSA isolates with a vancomycin MIC ≥2 mg/L. The final regression model included 6 independent predictors: chronic liver disease (adjusted odds ratio [aOR], 2.99; 95% confidence interval [CI], 1.39-6.42), prior recovery of MRSA from respiratory tract specimen (aOR, 2.54; 95% CI, 1.15-5.61), end-stage renal disease (aOR, 2.53; 95% CI, 1.33-4.78), severe sepsis or septic shock on presentation (aOR, 2.39; 95% CI, 1.28-4.44), prior vancomycin exposure (aOR, 2.21; 95% CI, 1.13-4.30), and recent hospitalization within 3 months (aOR, 2.11; 95% CI; 1.01-4.40). All independent predictors had a value of one point. Youden's index statistics indicated a score of ≥3 as best cutoff value that had a sensitivity of 69.6% and specificity of 78.4%. Simple decision rule helps clinicians stratify the risk of high vancomycin MIC MRSA infection when deciding empirical therapy for patients with community-onset infections.

Chen SY ，Hsueh PR ，Chiang WC ，Huang EP ，Lin CF ，Chang CH ，Chen SC ，Chen WJ ，Chang SC ，Lai MS ，Chie WC ... -  《-》

Impact of source of infection and vancomycin AUC0-24/MICBMD targets on treatment failure in patients with methicillin-resistant Staphylococcus aureus bacteraemia.

Despite recent controversies about toxicity and reduced efficacy, vancomycin remains the current treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. The parameter associated with treatment success is the vancomycin 24-h area under concentration-time curve to MIC ratio (AUC0-24/MIC). We aimed to determine the utility of calculated AUCs and explore the optimal AUC0-24/MIC targets associated with treatment success. In this single-centre retrospective observational cohort study of 127 patients with MRSA bacteraemia, forty-five (35.4%) did not respond to vancomycin treatment. Patient characteristics were essentially the same between those who did not respond to vancomycin treatment and those with treatment success, with independent predictors of treatment failure being source of bacteraemia (odds ratio (OR), 4.29; 95% confidence interval (CI), 1.50-12.26; p 0.007) and not achieving an AUC0-24/MICBMD (using broth microdilution) target of ≥398 (OR, 11.4; 95% CI, 4.57-28.46; p< 0.001). Bacteraemic source-specific thresholds were observed with a higher AUC0-24/MICBMD target of 440 required for high-risk sources (e.g. infective endocarditis) compared with 330 for low-risk sources (line related bacteraemia). Overall treatment success in patients with MRSA bacteraemia was associated with a vancomycin AUC0-24/MICBMD target of ≥398, with source-specific targets observed. Future vancomycin practice guidelines will need to take into account MIC methodology, source of bacteraemia and patient populations prior to setting targets and monitoring recommendations.

Ghosh N ，Chavada R ，Maley M ，van Hal SJ ... -  《-》

Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: support for consensus guidelines suggested targets.

Kullar R ，Davis SL ，Levine DP ，Rybak MJ ... -  《-》